Consider Risk Factors When Deciding Care Path for Postoperative Crohn’s Disease

For some patients with Crohn’s disease, starting medication soon after surgery is key to preventing recurrence; others may do well with monitoring alone. Understanding patient risk factors is key to making the right choice, says Cleveland Clinic Gastroenterologist Miguel Regueiro, MD.

That’s a change from how postoperative Crohn’s disease has been managed in the past, he said.

“Years ago, we used to say, ‘Come back when you have symptoms,’” Dr. Regueiro says. But clinicians now know that the majority of untreated patients are showing signs of endoscopic recurrence by the end of the first year after surgery, even though many of these patients are clinically silent or asymptomatic.

“One of the things that’s changed the most in the past 25 years is that we now recognize we need to monitor the patient for objective signs of Crohn’s disease recurrence,” he says.

Dr. Regueiro recently gave a keynote address on “Prevention of Postoperative Crohn’s Disease” at the annual conference of Advances in Inflammatory Bowel Diseases.

He says that, even as providers now know they need to act much sooner to prevent recurrence, there’s also a new understanding that monitoring is important for all patients, even those at low risk for recurrence.

“Not every patient who undergoes surgery for Crohn’s requires medicine after surgery,” he says.

Classic risk factors include a patient who continues to smoke after surgery, a history of previous resections, and having penetrating or fistulizing disease. More recently, studies have found that male gender and non-white race are also linked to increased risk.

Medical treatment options

The options for patients starting treatment after surgery are usually antibiotic or biologic medication.

Antibiotics, typically metronidazole, can delay recurrence, but patients must take them continuously to maintain benefits, and most cannot tolerate these drugs long-term, Dr. Regueiro notes.

The two biologics that have been most extensively studied for the prevention of postoperative Crohn’s disease are infliximab and vedolizumab.

“Recent studies have found that starting either biologic shortly after surgery prevents recurrence,” he says.

Monitoring typically begins with a fecal calprotectin test three months after surgery. If levels remain low, colonoscopy can be delayed until six months to one year after surgery. But if levels are high, the patient should undergo colonoscopy to check for endoscopic signs of recurrence.

While not yet widely available, monitoring can be done with intestinal ultrasound, which has been shown to be highly effective in detecting recurrence of Crohn’s disease, notes Dr. Regueiro.

“For centers that have access to it, that is a nice modality,” he said. “If it shows, yes, there’s Crohn’s on the stool test and on the ultrasound, then it may be possible to hold off on doing a colonoscopy in the future.”

Choosing the right care path

So how should providers decide whether to proceed with monitoring only after surgery or to start the patient on medication straight away?

“This is where risk factors are helpful,” Dr. Regueiro says. “If there’s a low risk for recurrence, someone, for example, who’s had fairly mild Crohn’s disease for 15 to 20 years and had their first surgery after a long period of time, that patient may be one whom we don’t begin treatment after surgery but monitor them closely instead.”

On the other hand, if a patient has had multiple prior surgeries or aggressive disease, “those are high-risk factors for recurrence would prompt us to start medication after surgery,” Dr. Regueiro says. “Cigarette smoking has been linked to higher rates of postoperative recurrence, and all of our patients should quit smoking for health reasons, but especially Crohn’s disease patients who have undergone surgery.”

Dr, Regueiro says it’s important to talk to patients and explain the reasoning behind the decision, whether monitoring or treatment.

“The patient may be seeing me after surgery and saying, ‘This is the best I’ve felt in years, I don’t want to go on medication,’” he says. “The subjective symptoms of Crohn’s disease are often not there after surgery.”

He also uses the post-surgery period to encourage lifestyle and dietary changes, even though he acknowledges there aren’t enough studies on the impacts of diet preventing Crohn’s disease recurrence after surgery.

“In my practice, I take the opportunity to focus on lifestyle, because I do think that makes a difference,” he says.

Looking ahead Regueiro is excited to see more precision medicine applied to Crohn’s disease, perhaps based on molecular differences detected in tissue samples, or the patient’s microbiome.

“There may be a more precise way for us to risk stratify for postoperative recurrence,” he said.